We are accepting new patients 18 and up. Currently, we have a waitlist. We will also use the following information to verify benefits, start a chart and put you on the list. This also allows Shayna and Dr. Blythe to assess your needs prior to coming in.

Steps to Making a New Patient Appointment:

Please complete the new patient form below. This is very important; all new patients must have this completed PRIOR to being considered for an appointment.

If you are using insurance, we will confirm your insurance benefits PRIOR to our first meeting. This process typically takes two business days.

**This form does not replace the new patient paperwork. This is for insurance verification and chart creation only.

If we believe another practitioner might be better suited for your treatment needs, we will help you with a referral.

Payment:

If this practice is not in your insurance network, you can self-pay and apply to your insurance for out of network benefits. We do work with a company that you may find helpful with this process: getbetter.co

Please note that once you have self-paid for a visit, we do not retroactively submit the visit to insurance. Please alert us ahead of your visit if you ever need to change your method of payment.

Office fees for self-pay patients are $125 ($150 for the first visit). Payment is due at the time of service. There is a $65 fee for no-shows and less than 24-hour notice of cancellation.

No refunds are given after a service has been rendered per appointment policy.

We take cash, check, credit/debit cards, and HSA/FSA cards.

New Patient Information

First Name *

Last Name *

Middle Name

Gender Identity

Street Address *

City *

State *

Zip

Primary Phone Number *

Phone Number Type

Secondary Phone Number

Phone Number Type

E-Mail *

Date of Birth (MM/DD/YYYY) *

Marital Status

Emergency Contact

Contact Full Name

Phone Number

Relationship

Work

Employer

Job Title

Phone Number

Address

Zip Code

Insurance

Will you be paying by insurance? If yes, insurance information below is required. *

Insurance Company

Member/Policy Number

Group Number

Insurance Contact Number

*Please bring your ID and insurance card to the first visit.

Information of Policy Holder or Financially Responsible Party (If Not Self)

Relationship to Patient

Policy Holder or Financially Responsible Party’s Full Name

Date of Birth (MM/DD/YYYY)

Phone Number

Address / Zip (If Different from Patient)

Referral Information

How were you referred to us?

Do you want Virtual or In person Visits?

We have a waitlist. Would you like to be placed on the waitlist?

Would you be interested in seeing Dr. Blythe’s fellow (student)?

What is your reason for seeking care now? If you are pregnant, please indicate how many weeks.

Office Policy Agreement

All cancellations/reschedules made at least 24 hours in advance of the scheduled appointment are not charged. If you late cancel or no show your new patient appointment, you will not be given another appointment option with this office. Late cancellations/reschedules and no-show appointments will be charged according to the current fee. Insurance will not be reimbursing you for this charge. For repeated no-shows or late cancel/reschedules, we reserve the right to charge, and all future appointments will be canceled until you are able to attend scheduled appointments without missing them.

This practice requires a credit/debit card on file to secure appointments. You will be asked to submit this number through the patient portal, which is a secure file. This card will be used primarily for no-show’s and late cancellations, and for copayment/co-insurance/session fees. By agreeing to the terms and providing your credit/debit card, you are acknowledging that you are aware that your card will be charged according to the office policies. After agreeing to the terms and providing your credit/debit card, if you contact your bank or card company to deny this charge, resulting in a “chargeback,” any additional fees associated with that chargeback will be added to the original missed appointment fee. Thank you for your cooperation with this necessary policy.

I agree to these office policies and give permission to charge the card on file accordingly. *

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I’m great at working with many communities but mostly I’ve been recognized as the funky house call therapist.